Form No.Rajasthan Knowledge Corporation Ltd. (RKCL)

Application Form for registration of RKCL`s Gyan Kendra (Authorized GK)

(2 Sets of Hard Copies alongwith soft copy on CD to be submitted through preferred PSA) Registration for the following course(s)/ More than one selection is permissible

Rajasthan State Certificate Course in Information technology ( RS – CIT ) Rajasthan State Certificate Course in Financial Accounting (RS-CFA) Rajasthan State Certificate Course in English Language (RS-CEL) Rajasthan State Certificate Course in Retail Management (RS-CRM)

Rajasthan State Certificate Course in Banking, Financial Services & Insurance (RS-CBFSI) Existing ITGK / GK Center Code :

1. Programme Support Agency (PSA) Information

a. PSA Code: RAJ_NIT_06

b. Name of the PSA: National Institute of Information Technology & Professional Studies (NIITAPS)

c. PSA Address: A-78/79 Subhash Nagar Shopping Center Jaipur-302016

2. Applicant Organization’s (AO) Information

a. Name of AO:______________________________________________________________________________________

b. Proposed AO (GK) Name:____________________________________________________________________________

( Note: This name will appear in all documents of RKCL in future as its Authorized Gyan Kendra, if approved)

c. Address: ___________________________________________________________________________________________

__________________________________________________________________________________________________

d. Ward No.:_____________________________ Ward Name: __________________________________________________

e City:__________________________________ Pin

f. Tehsil: __________________________ District: _____________________________ State:_________________________

g. Telephone Office: STD Code ___________ No.________________ Email Address ______________________________

h. Name and address of Nearest Post Office: ________________________________________

i. Name of Municipal corporation/council: _________________________________________

j. Type of Organization: (Tick √)

Private Limited Company Public Limited Company Trusts Society

Cooperative Society Partnership Proprietorship Other

k. Designation of the Competent Authority/Head/Owner of the AO: (Tick √)

1.Chairman 2.Managing Director 3.Director 4.Managing Trustee 5. Partner

6.Sole Proprietor 7. Principal 8. Registrar 9.Other

l. Brief Description of activities conducted by AO____________________________________________________________

_________________________________________________________________________________________________

AO(GK) Coordinator’s Signature PSA Coordinator’s Signature

3. Details of Competent Authority/Head/Owner of the AO

AttachSelfAttestedPhotograph

Full Name: _________________________________________________________________________

Gender :( Tick√) Male /Female . Date of Birth: ____________ (DD/MM/YYYY) PAN No.:____________

Qualifications (in chronological order):___________________________________________________

Address for correspondence: ___________________________________________________________

City: __________________________ Pin

Tehsil________________________District______________________State______________________

Telephone Office: STD ________Tel No. _______________ Resi. STD _____Tel No. _______________

Mobile No.____________ Email (1) _______________________ Email (2) _______________________

4. Bank Account Details of the AO:

Account No: Type of Account: Savings/Current

Account Name:------------------------------------- ------------------------- ------------------------- -------------------------- ---------- -------------------------------------------------------

Name of the Bank: Bank Branch,City

Tehsil: ----------------------------------------------------- District: --------------------------------------- State: ------------------------------------- Pin:

5. Payment Details: (The A/C Payee DDs or Pay order should be drawn in favour of Rajasthan Knowledge Corporation Limited,

payable at Jaipur Location on a nationalized bank only):

Details of Demand Draft

DD Amount:__________________ DD No. : __________________________ MICR Code: _______________________

Drawee Bank: ____________________________________________Branch: ______________DD Date: ____________

(This demand draft shall be returned to the AO, if application is rejected by RKCL)

6. Infrastructure Resources of the proposed Authorized GK:

a. Premises & General Infrastructure Resources (Please attach supporting documents with photographs)

To be filled by AO PSA RemarksPremises(Owned/Rented/Leased)

Total Area Sq. ft.

Counseling & Administration Area Sq. ft.

Lecture Room Sq. ft.

Laboratory Room Sq. ft.

Staff Room Sq. ft.

Library No of Books on IT & allied subjects

Other Infrastructure

Display Facility in lecture room(if any) OHP/LCD

Projector/Writing Board

Clean & Hygienic Drinking water facility

Toilets(Ladies & Gents Separate)

Pantry

UPS capacity KVA:

Backup time in min:

Diesel Generator Set KVA:

Air Conditioning Tonnes

Fans

Fire Safety

Parking Capacity for two wheelers

Please Note that Xeroxing or telephone booth activities should not be carried out in the area of Authorized Gyan Kendra

AO(GK) Coordinator’s Signature PSA

b. Computing Facilities installed at the proposed Gyan Kendrai. Hardware

No. CPU CPU RAM CDROM HDD Monitor Keyboard/ Head- Server/ PSA`s RemarkType Speed Type Capacity Size, Mouse Phone Client

Type1

2

3

4

5

6

7

8

9

10

(For additional information, please attach separate sheet)

ii. Local Area Networking, Internet, Peripherals

To be filled by AO PSA Remarks

Ethernet 10/100 Base T Switch CAT 5 structure Cabling with RJ 45

Patch Cables

Modem(Dial

up/Broadband/ISDN/Leased

Line)

Availability of an internet

Connection

Type of internet Connection &

Bandwidth

Name of ISP PERIPHERALS(Please write the specifications)

Scanner

Printer

CD Writer

Web Cam

Backup devices

Others

Licensed Software availability

Operating System(Server)

Operating system(Client)

Office Automation tools

Antivirus software suite

DTP Software

Others

AO(GK) Coordinator’s Signature PSA Coordinator’s Signature

c. Human Resource appointed at the Authorized Gyan Kendra (Please attach the bio-data) i. Center Coordinator

Name: ______________________________________________________________________

Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick√) Male /Female.

Qualifications: ____________________________________ Experience______ (No of months)

Mobile No _______________________________ Email Address _______________________

Present Address----------------------------------------------------------------------------------------------------------------------------------------------------------

Permanent Address----------------------------------------------------------------------------------------------------------------------------------------------------

ii. Faculty-1

Name: ______________________________________________________________________

Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick√) Male/Female.

Qualifications: ____________________________________ Experience______ (No of months)

Mobile No _______________________________ Email Address _______________________

Present Address----------------------------------------------------------------------------------------------------------------------------------------------------------

Permanent Address----------------------------------------------------------------------------------------------------------------------------------------------------

iii. Faculty-2

Name: ______________________________________________________________________

Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick√) Male /Female

Qualifications: ____________________________________ Experience______ (No of months)

Mobile No _______________________________ Email Address _______________________

Present Address----------------------------------------------------------------------------------------------------------------------------------------------------------

Permanent Address----------------------------------------------------------------------------------------------------------------------------------------------------

iv. Counselor

Name: ______________________________________________________________________

Date of birth: ________________ (DD/MM/YYYY) Gender :( Tick√) Male/Female

Qualifications: ____________________________________ Experience______ (No of months)

Mobile No _______________________________ Email Address _______________________

Present Address----------------------------------------------------------------------------------------------------------------------------------------------------------

Permanent Address----------------------------------------------------------------------------------------------------------------------------------------------------

AO (GK) Coordinator’s Signature PSA Coordinator’s Signature

7. Declaration by AO(GK)

I/we wish to apply to register our center as the Authorized GK for conducting RKCL’s course(s) at our above mentioned premises.

I/we have been provided with adequate training and orientation by PSA ________________________________

on the methodology of conducting course(s). I/we further undertake to implement the course in accordance with and complete adherence to RKCL norms as decided from time to time and as published on RKCL’s website.

I/we further undertake that I/we shall be responsible for all costs, consequences, expenses, liabilities, obligations, and

damages brought against or suffered by RKCL resulting from or arising out of or relating to any discrepancies, acts,

omissions, negligence, misrepresentation, and malpractice whether directly or indirectly, committed by me/us,

subsequent to registration as the Authorized Gyan Kendra. I also understand the following:

1. Changing of address: After agreement if there is any change in address then it will be charged at the rate ofRs. 1000/- per Gyan Kendra along with notarized affidavit subject to RKCL’s approval. Address change will be permitted only once in a year.

2. Minimum Business Guarantee: It will be responsibility of me/us to admit at least 50 learners during one year fromthe date of this agreement and committed the same for any further renewal of time of agreement.

3. New Course: We shall pay the charges of new courses as introduced by RKCL from time to time as per RKCL termsand conditions. If we opt for such new courses.

4. Renewal of Agreement: We shall agree and pay the renewal charges of IT-GK/GK as decided by RKCL from timeto time.

5. Sliding Charges: Pay sliding charges (As decided by RKCL from time to time) if we/us wish to change ourProgramme Support Agency (PSA) as and when RKCL permits.

6. We shall open a current account with the nationalized bank and get our share directly in our bank account for which we shall submit necessary information/document to PSA/RKCL.

7. Infrastructure: Infrastructure at ITGK /Study Center will be as mentioned on RKCL’s Website.( www.rkcl.in)and will be updated/improved from time to time as per RKCL’s instructions / requirement.

8. Refund of Payment: The amount deposited with this application will not be refundable in any case, once the centrecode is generated by RKCL.

9. This is our request application which is a consent from my/our side to be an authorized ITGK/GK of RKCL.

10. We understand that this application does not mean our confirmation of our center as authorized ITGK/GK of RKCL our registration is subject to approval of RKCL.

Name of competent authority: _____________________________________________________

Designation ___________________________

Date _______________________

Place ___________________

Seal & Signature of Competent Authority/Head/Owner of AO (GK)

(AO should attach to this application form photographs (4” x 6”) of the interior & exterior view of the proposed premises,

computer lab, classrooms, etc. and relevant certificates as applicable)